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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORINI�G NOWELL
<br /> Co�ntyName WELL AND BORWG RECORD .� � �� ��
<br /> H Minnesota Siatutes,Chapter f037
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> Q ,� ,� y, tt.
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude _ degrees minutes seconds
<br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven U Dug
<br /> ❑Auger �Rotary ❑Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �
<br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. �.teC From ft.To ft.
<br /> . Showing property lines,
<br /> ; N �a��uildings,and direction. USE �'Domestic ❑Monitoring ❑Heating/Cooling `
<br /> ��.
<br /> � __i___ __1_____i_____i__ ..� � ❑Noncommunity PWS L�Environ.Bore Hole �]Industry/Commercial ;
<br /> ❑Community PWS (J Irrigation ❑Remedial
<br /> �-� --i--- --`-- ---F-----'-- ❑Elevator �]Dewatering ❑ '�
<br />� �� �' , , , , E� _ CASING MATERIAL Oe� �a HOLE DIAM.
<br /> , , , , �':Y� Dr
<br /> �. ive Sh ❑Yes �
<br /> --+--- ---'--- ---F-----*-- r
<br /> \`�- ❑Steel ❑Threaded ❑Welded
<br /> � , , , Mile StiC
<br /> . , , . I ; ,�Pla ❑
<br /> --�--- --�-----�—---%- � ' '
<br /> 1 CASING
<br /> � � S � � , x�� Diameter Weight Specifications
<br /> I �7
<br /> �1 Mile—� �in.to �.Q/ ft. �.� __Ibs./ft. Alii'R! �_in.to�.ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �in.to��ft.
<br /> " T("� �■�tZ in.to ft. Ibs./ft. in.to ft.
<br /> Property owner's mailing address if different than well location address indicated above. SCREE♦N�_L___
<br /> OPEN HOLE
<br /> .. 25$ �T'�mpt PL8�� Make alVli� From ft. To ft.
<br /> ��� ` Type }4}'R��'t�AfRII At*� Diam. ��
<br /> Or�> I�t 55356 SIoUGauze �1'14[l Length_1.��,'��i
<br /> Set between ft.and ft. FITTINGS
<br /> STATIC WATER LEVEL
<br /> Measured from
<br /> � ft.�Below ❑Above land surface Date measured_�wZl��
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br />� 1� ft.after 1�5 hrs.pumping � g.p.m.
<br />( Well/boring owneYs mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION Ry,�
<br /> E �Pitless/adapter manufacturer �ju�e�te`� � Model
<br /> i ❑Casing Protection �2 in.above grade
<br />� ❑At-grade(Environmental Well and Boring ONLY)
<br />' GROUTING INFORMATION
<br />. Well grouted ,{�Yes ❑No ,�(
<br /> Grout materials [�Neat cement ey.Bentonite ❑Concrete ❑Other
<br /> From Q To � ft. �_ ❑Yda �Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From � To�RI$T.ural fift]ji'ds. ❑Bags
<br /> MATERIAL
<br /> From��T � ❑Yds. ,�Bags
<br /> ♦ NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> Cia}1 gray ft � W f.�� _teet �"' direction s-���,,,,>>`x+ryp
<br /> �p� ��rp/� Well disinfected upon completion? �Yes ❑No �,,.,,_ '��,�;,3'-a._.e�
<br /> '"""' 'p�$,y fC VlJ Z�S PUMP
<br /> t
<br /> [�_�Not installed Date installed__ . "
<br /> Manufacturer's name �t�'lOt�C
<br /> Model Number HP��� Volts �-^�
<br /> Length of drop pipe �� ft. Capacity __g.p.m.
<br /> Type:�Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
<br /> ABANDONED WELLS -
<br /> Does property have any not in use and not sealed well(s)? ❑Yes �No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ❑Yes ,�No TN#
<br /> WELL CONTRACTOR CERTIFICATION
<br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> The information contained in this report is true to the best of my knowledge.
<br /> Use a second sheet,if needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc.
<br /> �tE�EIVED � Stodola Well Dri2ling �o,. Inc. 1b91
<br /> Licensee Business Name Lic.or Reg.No.
<br /> � ��;'
<br /> DE� 31 2007 � � � � : � :, i2-i�-o7
<br /> i resentative ignature Certified Rep.No. Date
<br /> LOCAL COPY 7 �0 6 9 7 -- `�` '`�°`�
<br /> Name of Driller
<br /> IC 140-0020 HE-01205-10(Rev.6/O6)
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